Sheppard James P, Lown Mark, Burt Jenni, Ford Gary A, Hobbs F D Richard, Little Paul, Mant Jonathan, Payne Rupert A, McManus Richard J
Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom.
Primary Care Research Group, University of Southampton, Southampton, United Kingdom.
Front Pharmacol. 2021 Apr 20;12:619088. doi: 10.3389/fphar.2021.619088. eCollection 2021.
Deprescribing of antihypertensive drugs is recommended for some older patients with polypharmacy, but there is little evidence to inform which drug (or dose) should be withdrawn. This study used data from the OPTiMISE trial to examine whether short-term outcomes of deprescribing vary by drug class and dose of medication withdrawn. The OPTiMISE trial included patients aged ≥80 years with controlled systolic blood pressure (SBP; <150 mmHg), receiving ≥2 antihypertensive medications. This study compared SBP control, mean change in SBP and frequency of adverse events after 12 weeks in participants stopping one medication vs. usual care, by drug class and equivalent dose of medication withdrawn. Equivalent dose was determined according to the defined daily dose (DDD) of each medication type. Drugs prescribed below the DDD were classed as low dose and those prescribed at ≥DDD were described as higher dose. Outcomes were examined by generalized linear mixed effects models. A total of 569 participants were randomized, aged 85 ± 3 years with controlled blood pressure (mean 130/69 mmHg). Within patients prescribed calcium channel blockers, higher dose medications were more commonly selected for withdrawal (90 vs. 10%). In those prescribed beta-blockers, low dose medications were more commonly chosen (87 vs. 13%). Withdrawal of calcium channel blockers was associated with an increase in SBP (5 mmHg, 95%CI 0-10 mmHg) and reduced SBP control (adjusted RR 0.89, 95%CI 0.80-0.998) compared to usual care. In contrast, withdrawal of beta-blockers was associated with no change in SBP (-4 mmHg, 95%CI -10 to 2 mmHg) and no difference in SBP control (adjusted RR 1.15, 95%CI 0.96-1.37). Similarly, withdrawal of higher dose medications was associated with an increase in SBP but no change in BP control. Withdrawal of lower dose medications was not associated with a difference in SBP or SBP control. There was no association between withdrawal of specific drug classes and adverse events. These exploratory data suggest withdrawal of higher dose calcium channel blockers should be avoided if the goal is to maintain BP control. However, low dose beta-blockers may be removed with little impact on blood pressure over 12-weeks of follow-up. Larger studies are needed to confirm these associations.
对于一些患有多种药物治疗的老年患者，建议停用抗高血压药物，但几乎没有证据表明应停用哪种药物（或剂量）。本研究使用了OPTiMISE试验的数据，以检验停用药物的短期结果是否因药物类别和停用药物剂量而异。OPTiMISE试验纳入了年龄≥80岁、收缩压（SBP）得到控制（<150 mmHg）且正在接受≥2种抗高血压药物治疗的患者。本研究比较了在停用一种药物的参与者与常规治疗组中，12周后按药物类别和停用药物的等效剂量划分的SBP控制情况、SBP的平均变化以及不良事件的发生频率。等效剂量根据每种药物类型的限定日剂量（DDD）确定。低于DDD开具的药物被归类为低剂量，开具剂量≥DDD的药物被描述为高剂量。通过广义线性混合效应模型对结果进行检验。共有569名参与者被随机分组，年龄为85±3岁，血压得到控制（平均130/69 mmHg）。在开具钙通道阻滞剂的患者中，更常选择停用高剂量药物（90%对10%）。在开具β受体阻滞剂的患者中，更常选择停用低剂量药物（87%对13%）。与常规治疗相比，停用钙通道阻滞剂与SBP升高（5 mmHg，95%CI 0 - 10 mmHg）和SBP控制率降低（调整后RR 0.89，95%CI 0.80 - 0.998）相关。相比之下，停用β受体阻滞剂与SBP无变化（-4 mmHg，95%CI -10至2 mmHg）以及SBP控制无差异（调整后RR 1.15，95%CI 0.96 - ）相关。同样，停用高剂量药物与SBP升高但血压控制无变化相关。停用低剂量药物与SBP或SBP控制无差异无关。停用特定药物类别与不良事件之间无关联。这些探索性数据表明，如果目标是维持血压控制，应避免停用高剂量钙通道阻滞剂。然而，在12周的随访中，停用低剂量β受体阻滞剂对血压的影响可能较小。需要更大规模的研究来证实这些关联。
